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Great expectations

01 May 2011

Miss B was a 20-year-old university student who had suffered marked breast asymmetry since puberty. As she got older the problem started to cause her real embarrassment in social relationships. She made an appointment to see Mr M, a local consultant plastic surgeon, and took her sister along for moral support.

Later, the surgeon recalled that he had found the consultation difficult because of the clearly high expectations of Miss B and the fact that perfect correction of breast asymmetry is a most demanding procedure. For that reason, he recalled, he had offered Miss B a further consultation to allow her to raise any further concerns and to have any outstanding queries answered.

At one consultation her sister took copious notes throughout the meeting. She did not want to inform her family doctor of the procedure. The procedure – a right mastopexy and left mastopexy combined with insertion of a saline implant to the smaller breast to correct asymmetry – was uneventful.

Perioperative antibiotics were administered. However, within a few days, Miss B was re-admitted with an infection that required the implant to be removed and further antibiotics administered. The infection was slow to settle and ultimately the incision healed with an unsightly wide, hyperpigmented scar, not to mention that the implant had been lost and the asymmetry, which was the prime indication for the surgery, persisted.

Miss B failed to keep further appointments without getting in contact, and eventually a solicitor’s letter arrived making a claim against Mr M. When the case came to review, it was hard to fault either the surgery or the follow-up. However, the details of what had been discussed at the pre-operative consultations were scanty. There was no evidence that the surgeon had warned about the possibilities of infection or prominent scars. Therefore the case had to be settled for a moderate sum.

Learning points

  • Patients who request cosmetic surgery have issues that are quite different from those of patients requiring other types of surgery. It is vital to assess the suitability and preparedness of patients within this group. Not infrequently, such patients may also have lesser or greater degrees of distortion of their own body image, which need to be taken into account in patient selection.
  • It is crucial to assess the patient’s expectations and to be clear as to whether these are likely to be met, bearing in mind the potential for variability of outcome in cosmetic procedures.
  • Consider psychological referral if there is any question of body dysmorphia in a patient.
  • Surgeons should discuss all the relevant complications for a given procedure and document this discussion. This should be not only in the form of written notes, but clearly summarised in any correspondence to the family doctor and copied to the patient. Documenting consent is particularly important in plastic surgery cases and you should document a patient’s expectations and any mitigation you have put against their expectations.
  • In those instances where the patient does not wish the family doctor to be informed, which should itself raise concerns, then a good course of action is for the surgeon to write to the patient summarising the discussion. It is also increasingly recognised that providing the patient with an advice sheet summarising the planned procedure and listing specific potential complications is good practice.
  • Difficult consultations should always ring warning bells and be documented. A cooling off period followed by a second consultation is often valuable.
  • Pre and postoperative photographs form part of a patient’s medical records and consent should be taken.